Rhode Island Medicaid Appeals: Fight a Denial, Keep Coverage

If Rhode Island denied, cut, or terminated your Medicaid, you have 35 days from your Benefit Decision Notice to request a fair hearing, and coverage keeps flowing while you appeal.1 That window is shorter than the federal ceiling of 90 days, so read the deadline off your own notice and do not assume you have longer; either way, you keep the right to appeal and request a fair hearing before the state.2,3

In This Guide

• What you can appeal in Rhode Island Medicaid
• What are the deadlines to appeal Rhode Island Medicaid?
• How to keep your benefits during a Rhode Island Medicaid appeal
• Managed care (MCO) appeals in Rhode Island Medicaid
• How to request a Rhode Island Medicaid fair hearing

What you can appeal in Rhode Island Medicaid

Federal law guarantees every Medicaid applicant and beneficiary a fair hearing before the state agency. Section 1902(a)(3) of the Medicaid statute (42 USC 1396a(a)(3)) requires a hearing for anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness, and the implementing rule at 42 CFR 431.220 extends that right to anyone who believes the agency made an adverse determination.3

In Rhode Island, that right lets you appeal:

• A denial of your application (income, assets, household composition, or documentation)
• A termination or reduction of your eligibility or of a covered service
• A cut to authorized service hours, such as personal care or home care
• A prior-authorization denial or a level-of-care determination
• A managed care plan's denial, reduction, suspension, or termination of a service

You register that disagreement by requesting a fair hearing, where an administrative hearing officer reviews your case and decides whether the agency acted correctly.1

What are the deadlines to appeal Rhode Island Medicaid?

Which window governs you depends on who acted and what they decided. Four different clocks can apply to a Rhode Island Medicaid appeal:

For an eligibility decision, Rhode Island's 35-day window is shorter than the federal ceiling of a reasonable time not to exceed 90 days from the date the notice is mailed.1,2 A managed care plan's denial runs on its own clock: you have 60 calendar days to file the plan's internal appeal,4 and once the plan resolves that appeal against you, the state gives you no fewer than 90 and no more than 120 calendar days to request a state fair hearing.5 If your coverage ended only because you did not return a renewal form on time, 42 CFR 435.916 requires the agency to reconsider your eligibility without a new application when you submit the renewal form within 90 days after the termination date. That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Rhode Island may offer the same window but is not required to, so ask DHS.6

How to keep your benefits during a Rhode Island Medicaid appeal

In Rhode Island, your Medicaid coverage continues automatically during the appeal process, and you do not have to repay the state for medical care you received even if you lose the hearing.1 That automatic continuation is Rhode Island's version of a federal guarantee: under 42 CFR 431.230, when the agency sends the required advance notice and you request the hearing before the date the action takes effect, your services cannot be terminated or reduced until a decision is rendered after the hearing.1

Two dates matter, and they are not the same date. To be certain your coverage never lapses, file your appeal before the date the action on your notice takes effect, not after it. Filing within the 35-day window keeps your appeal rights alive; filing before the action date is what keeps the benefits flowing while you wait for a decision.1

Managed care (MCO) appeals in Rhode Island Medicaid

Rhode Island runs Medicaid through managed care organizations (MCOs), the health plans that deliver most members' services. Members who are not also enrolled in Medicare choose one of three plans: Neighborhood Health Plan of Rhode Island (1-800-459-6019), Tufts Health Plan (1-866-738-4116), or UnitedHealthcare Community Plan (1-800-587-5187).1 When your plan denies care, you appeal to the plan before you reach a state fair hearing.5 These rules come from the federal managed care regulations at 42 CFR Part 438.

What counts as a plan denial

Under 42 CFR 438.404, the plan must give you timely, written notice of an adverse benefit determination, and for a termination, suspension, or reduction of a previously authorized service that notice must be mailed within the federal advance-notice timeframes. The notice must tell you how to appeal, how to request an expedited appeal, and how to ask that your benefits continue while the appeal is decided.7

The internal appeal and exhaustion

You have 60 calendar days from the date on the determination notice to file the plan's internal appeal, which you can request orally or in writing.4 The plan has one level of appeal, and you must complete it before requesting a state fair hearing.5 If the plan misses its own notice or timing rules, federal law deems that appeal exhausted, so you can go straight to the state fair hearing.5

How fast the plan must decide

The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours of receiving it. Either timeframe can be extended by up to 14 calendar days if you request the extension or the plan shows the state that more information is needed and the delay is in your interest.5

After the plan upholds its denial

Once the plan's internal appeal is decided against you, you then have the state's 90-to-120-day window to request a fair hearing with the EOHHS Appeals Office.5

How to request a Rhode Island Medicaid fair hearing

The EOHHS Appeals Office conducts Rhode Island's Medicaid fair hearings, where an administrative hearing officer reviews your case.1 You can request a hearing four ways:

• Online. Log into your account at healthyrhode.ri.gov and click "file an appeal."
• By phone. Call HealthSource RI at 1-855-840-4774.1
• In person. Visit a DHS office and bring the appeal form included in every Benefit Decision Notice.
• By mail. Send the completed appeal form to ATTN: Appeals, State of Rhode Island, P.O. Box 8709, Cranston, RI 02920-8787.

At the hearing, you may represent yourself or be represented by anyone you choose, including an attorney, an advocate, a friend, or a relative.8 Free legal help may be available through the Rhode Island Parent Information Network (RIPIN) (401-270-0101) or Rhode Island Legal Services (401-274-2652).1

Learn More

Find personalized help navigating a Rhode Island Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.